Treatment

Seek expert advice.

In treating a patient with OCD the health professional must bear in mind that:

• the condition may run a chronic, fluctuating course and have long periods of remission
  
  
• depressive disorder often accompanies obsessional neurosis and treatment of the depressive state may lead to spontaneously resolution of obsessional symptoms
  
  
• the patient often believes that they are developing a more severe mental disorder; an important aim when initiating therapy is to explain that OCD does not progress in this way

Treatment may involve psychotherapy, drugs or other physical treatments. The treatment most often is a combination of serotonin reuptake inhibitors and behavioural therapy.

Review of the evidence suggests that benefiicial treatments in this condition are (1):

• behavioural therapy
• cognitive therapy
• serotonin reuptake inhibitors

NICE state (2):

• adults with OCD
  • in the initial treatment of adults with OCD, low intensity psychological treatments (including exposure and response prevention [ERP]) (up to 10 therapist hours per patient) should be offered if the patient's degree of functional impairment is mild and/or the patient expresses a preference for a low intensity approach. Low intensity treatments include:
    • brief individual cognitive behavioural therapy (CBT) (including ERP) using structured self-help materials
    • brief individual CBT (including ERP) by telephone
    • group CBT (including ERP) (note, the patient may be receiving more than 10 hours of therapy in this format)
  • adults with OCD with mild functional impairment who are unable to engage in low intensity CBT (including ERP), or for whom low intensity treatment has proved to be inadequate, should be offered the choice of either a course of a selective serotonin re-uptake inhibitor (SSRI) or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious
  • adults with OCD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious

A review suggests an algorithm for management of OCD (3):

Initial Assessment

• Confirm OCD diagnosis, severity, comorbidities, and patient preferences.

First Line Treatments

• ERP (Exposure and Response Prevention).
• SSRIs or clomipramine.
• Combination of ERP + medication.

If Response is Inadequate (Step 2)

1. Consider second line therapies:

• ACT (acceptance and commitment therapy), CT (cognitive therapy), I-CBT (inference based cognitive behavioral therapy), or metacognitive therapy.
• Alternative SSRIs or SNRIs.

2. Adjunctive approaches:

• Mindfulness.
• DBT (dialectical behavior therapy) skills.
• Adjunctive medications (e.g., atypical antipsychotics).

If Response is Inadequate (Step 3)

Third line treatments:

• rTMS (Repetitive Transcranial Magnetic Stimulation).
• DBS (Deep Brain Stimulation).
• Neurosurgery (reserved for severe cases as a last resort).

If Response is Inadequate (Step 4)

Emerging/experimental treatments:

• Ketamine or psychedelics (strictly within a research setting).

Throughout Treatment

• Monitor progress and adjust based on response.
• Engage the patient throughout the process.
• Add self-help and support groups.

Notes (2,4):

• OCD in pregnancy
  • if a woman is taking medication alone, stopping the drug and starting psychological therapy should be considered
  • if she is not taking medication, starting psychological therapy should be considered before drug treatment
  • if she is taking paroxetine, it should be stopped and switching to a safer antidepressant considered
• pregnant woman with OCD who is planning to breastfeed
  • use of a combination of clomipramine and citalopram should be avoided if possible.
• women who have a new episode of OCD while breastfeeding
  • the combination of clomipramine and citalopram should be avoided because of the high levels in breast milk

Reference:

1. Clin Evid Concise 2003;10:229-230.
2. NICE (2005).Obsessive-compulsive disorder
3. Abramowitz J S, Abramovitch A, McKay D, Draffin A. Management of obsessive-compulsive disorder in adults. BMJ 2026; 392 :e083443.
4. NICE (2007). Antenatal and postnatal mental health.